Medical Records

Robinson Oaks Wellness & Rehabilitation; Denton (TX); On-site; USD 52,000 - 68,000; Full time

Job summary

Robinson Oaks Wellness and Rehabilitation in Denton, TX is seeking a Records Coordinator to maintain resident medical records in compliance with federal and state regulations, HIPAA, and company policies. You will ensure accuracy from pre-admission to post-discharge.

The role requires ICD coding knowledge, meticulous attention to detail, and strong communication with residents, families, staff, physicians, and regulators. Monday through Friday, 8am to 5pm, on site.

Qualifications

• Knowledge of HIPAA, federal and state regulations pertaining to long-term care.
• Knowledge of medical terminology, laws, and regulations as they pertain to long term care.
• Effective communication skills to maintain positive relationships with residents, families, staff, physicians, consultants, providers, and agencies.
• Maintains neat, well-groomed and professional appearance.

Responsibilities

• Manages resident health information by ensuring records are accurate, complete, current, confidential, and compliant with regulations.
• Ensures accurate and current diagnostic coding to maximize billing and improve cash flow.
• Establishes procedures for collection, coding and indexing, and the filing/retrieving of medical records; performs ICD coding; creates medical records for all new admissions.
• Knowledgeable of federal and state laws regarding medical records; maintains records accurately and timely; performs monthly audits on admissions, discharge, and QA.
• Reviews and audits admissions, discharges, change of condition, and other records on nursing units; conducts routine audits to monitor documentation and physician visits.
• Other duties, responsibilities and activities may change or be assigned at any time.

Skills

HIPAA compliance

Medical terminology

Communication skills

Attention to detail

Education

RHIA or RHIT credential preferred

Tools

ICD coding

Job description

Schedule

Monday-Friday 8am-5pm

Position Description

Responsible for maintaining resident medical records in accordance with State and Federal regulations, professional standard of practice and company policy and procedure. Responsible for ensuring the management and accuracy of medical resident records from pre-admission to post discharge.

Principal Responsibilities

• Manages resident health information by ensuring resident records remain accurate, complete, current, confidential, and are compliant with federal and state regulations, HIPAA, and company policies and procedures.
• Ensures accurate and current diagnostic coding to assure appropriate billing, to maximize accounts receiving and improve cash flow.
• Establishes and executes procedures in the collection, coding and indexing, and the filing/retrieving of medical records; Performs ICD coding; creates medical records for all new admissions.
• Must be knowledgeable on federal and state laws regarding medical records; Ensures resident records are maintained accurately and timely according to local, state and federal regulations; Performs monthly audits on: admissions, discharge and routine Quality Assurance
• Reviews and audits admissions, discharges, change of condition, and other pertinent records on nursing units; Performs routine audits of medical records upon admissions, throughout the stay, and discharge to monitor compliance with policies regarding documentation, physician visits, timeliness, etc.
• Other duties, responsibilities and activities may change or assigned at any time with or without notice.

Qualifications

• RHIA or RHIT credential preferred.
• Minimum of 2 years’ experience in medical records in skilled nursing facility or healthcare related field.
• Experience with ICD coding preferred.
• Knowledgeable of medical terminology, laws, and regulations, as they pertain to long term care.
• Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives and the community.
• Maintain neat, well-groomed and professional appearance.

Robinson Oaks Wellness and Rehabilitation provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.